Root Cause Analysis Design and Its Application to Pharmacy Education

To evaluate third-year pharmacy students’ ability to effectively design and apply root cause analysis (RCA) to a sentinel event and to analyze student responses for areas of proficiency and deficiency. This study involved a comprehensive review of RCA key assessments from 82 students in spring 2014. The performance assessments consisted of a review of each student’s RCA worksheet and flow diagram as well as the 1-2 page narrative reflection. The majority of students were able to successfully design an RCA, but had challenges with 3 components: fact-finding session, disclosure plan, and a flow diagram. Several students perceived challenges to conducting a formal RCA in certain health care settings, which included assembling an RCA team and gathering relevant facts, a lack of transparency/safe environment within organizations, and creating a plan for multiple/sequential errors. Most students were able to design an RCA process, but encountered difficulty with some components. Students also identified challenges in applying the approach in certain health care arenas.